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MRCP PACES Neurology > Neuroscience and Neurology Examinations > Flashcards

Neuroscience and Neurology Examinations Flashcards

1
Q

Biceps reflex

A

C5, C6

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2
Q

Brachioradialis reflex

A

C5, C6

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3
Q

Triceps brachii reflex

A

C6, C7

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4
Q

Knee jerk reflex

A

L3, L4

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5
Q

Ankle reflex

A

S1

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6
Q

MRC power grading scale

A

0 - no movement at all
1 - flicker or trace contraction
2 - active movement when gravity eliminated
3 - active movement against gravity
4 - active movement against gravity and resistance
5 - normal full strength

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7
Q

Action: Shoulder abduction
- Muscle, nerve, myotome

A

Deltoids
Axillary nerve
C5

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8
Q

Action: Elbow flexion
A. supinated ; B. half pronated
- Muscle , nerve, myotome

A

A. Supinated
Biceps, brachialis
Musculocutaneous nerve
C5, C6

B. Half pronated
Brachioradialis
Radial nerve
C5, C6

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9
Q

Action: Elbow extension
- Muscle, nerve, myotome

A

Triceps brachii
Radial nerve
C7

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10
Q

Action: wrist extension
- Muscle, nerve, myotome

A

Wrist extensors and finger extensors
Radial nerve
C6

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11
Q

Action: fingers flexion
- Muscle, nerve, myotome

A

FDS and FDP
FDS: median nerve
FDP: median and ulnar nerves
C8

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12
Q

Action: fingers abduction
- Muscle, nerve, myotome

A

Dorsal interossei, abductor digiti minimi
Ulnar nerve
T1

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13
Q

Action: hip flexion
- Muscle, nerve, myotome

A

Iliopsoas, quadriceps
L1-L3 root (iliopsoas)
L1, L2, L3

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14
Q

Action: hip extension
- Muscle, nerve, myotome

A

Gluteus maximum
Inferior gluteal nerve
L5, S1

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15
Q

Action: hip abduction and internal rotation
- Muscle, nerve, myotome

A

Gluteus medius, gluteus minimum, tnsor fasciae latae
Superior gluteal nerve
L5

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16
Q

Action: knee extension
- Muscle, nerve, myotome

A

Quadriceps femoris
Femoral nerve
L3, L4

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17
Q

Action: knee flexion
- Muscle, nerve, myotome

A

Hamstring (2 pairs: long/short bicep femoris laterally; semitendinosus and semimembranosus medially)
Sciatic nerve
S1

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18
Q

Action: ankle dorsiflexion
- Muscle, nerve, myotome

A

Tibialis anterior
Deep peroneal nerve
L4, L5

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19
Q

Action: ankle plantar flexion

A

Gastrocnemius
Tibial nerve
S1

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20
Q

Action: hallux extension
- Muscle, nerve, myotome

A

Extensor hallucis longus
Deep peroneal nerve
L5

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21
Q

Action: ankle eversion
- Muscle, nerve, myotome

A

Peroneus longus and brevis
Superficial peroneal nerve
L5, S1

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22
Q

Action: ankle inversion
- Muscle, nerve, myotome

A

Tibialis posterior, tibialis anterior
Tibial and deep peroneal nerve
L4

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23
Q

Spinothalamic

A

Pain, temperature

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24
Q

Dorsal column medial lemniscus (DCML)

A

fine touch, proprioception, vibration (128Hz tuning fork)

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25
Q

Where to place tuning fork?
A. Upper limbs
B. Lower limbs

A

A. Upper limbs
- Distal or proximal IPJ
- MCPJ
- Radial or ulnar styloids
- Olecranon
- Clavicle

B. Lower limbs
- IPJ of big toe
- Medial or lateral malleoli of ankle
- ASIS

26
Q

Neurology presentation format
(Except cerebellar syndrome and Parkinson’s disease)

A
  1. Spastic / flaccid
  2. Distribution - monoparesis, hemiparesis, paraparesis, tetraparesis
  3. Site - left/right ; upper or lower limb
  4. Upper or lower motor neuron signs
    4A. Elaborate reason - tone, reflexes
  5. Chronicity
    - UMNL: contracture
    - LMNL: wasting
  6. Functional status
27
Q

Inspection and exposure of UL and LL examination

A

Both must be full inspection of UL and LL
- Why?
Wasted thighs + shoulder - proximal myopathy
Wasted fingers and distal muscles - distal myopathy

Expose:
- Upper limbs
- Lower limbs
- Upper back
- Neck
- Head

28
Q

Sequence of examination of upper limbs
(m: EIM FTRPSCPV)

A

Exposure: Remove shirt and expose lower limbs

Inspection: surroundings for aids; patient’s head, neck, shoulder, back, arms for wasting, scars, abnormalities

4 manoeuvers: pronator drift, wrist hyperextension, sustained 3 seconds myotonic grips, fasciculations
- Pronator drift fully supinated and straight, fully adduct fingers
- Wrist and finger hyperextension - wrist drop
- Grip myotonic sustained 3 seconds clench then open
- Fasciculations (controversial)

Tone
Reflexes
Power

Sensation - touch (dorsal column) ; pain (spinothalamic)
Coordination: past pointing, dysdiadochokinesia
Proprioception: thumb - ask patient to close eyes, stabilize joints
Vibration with 128Hz tuning fork (dorsal column)

29
Q

Tone of Upper Limb

A

Varying speed
- Slow passive movement first (to elicit hypotonia)
- Then fast movement (to elicit Parkinsonism)
Full range of motion
Single joint

  1. Passive elbow flexion/extension
  2. Passive wrist flexion/extension
  3. Passive pronation/supination - pronator teres
    - Elbow at 90 degree
    - Supinate quickly, pronate slowly for supinator catch
30
Q

Reflexes of Upper Limb

A

Both arms in rested position, 90 degrees
Hit at right speed, let tendon hammer drop, do not pull back
If correctly position does not even need to move to opposite side

  1. Biceps reflex C5/C6
  2. Triceps reflex C6/C7
  3. Brachioradialis reflex C5/C6- use own thumb to isolate patient’s thumb
31
Q

Power of Upper Limb

A

Shoulder abduction
Shoulder adduction - kiap, don’t let me pull

Elbow flexion and extension
- 90 degree, stabilise elbow with the other hand (prevents use of latissimus dorsi)

Wrist flexion and extension -
No need like for like with wrist, just use ulnar aspect of hand

Finger abduction
Finger adduction - pull with paper
Thumb abduction/adduction

32
Q

Sensation of upper limb - 7-8 points

A

Mainly pain sensation for spinothalamic_
Deltoid regimental badge - axillary nerve / C5
Arm lateral - C5 + radial

Forearm lateral - C6 + musculocutaneous
Thumb - C6 + median

Middle finger - C7

Little finger - C8 + radial
Forearm median - C8 + cutaneous

Arm medial - T1

If proprioception/vibration impaired, proceed to test fine touch - DCML
Do not stroke with cotton bud!
- Stroking activates nociceptors and itch -> becomes testing for spinothalamic tract

33
Q

Nosetip to fingertip test

A

Touch your nose tip, then touch my finger tip
- Jerking and hesitancy
- Past pointing
- Depth perception

Both touching finger tip and returning to nose tip are equally important cerebellar signs!

34
Q

Sequence of examination of lower limbs
(m: EI FTRMBPSCPV RG)

A

Exposure: Remove pants ideally - inguinal to toes and shirt
Inspection: surroundings for aids; patient’s neck, shoulder, back, arms for wasting, scars, abnormalities
Fasciculations
Tone
Reflexes
Myoclonus - 3 or more beats
Babinski
Power
Sensation - touch (dorsal column) ; pain (spinothalamic)
Coordination: heel shin test
Proprioception: big toe
Vibration with 128Hz tuning fork (dorsal column)
Romberg and Gait

35
Q

Tone of Lower Limb

A

Roll thighs
- Move slowly then fast for rigidity

Passive knee flexion/extension
- If legs go off the bed - spasticity
- if legs draggy - flaccid

Do not test myoclonus yet at this point

36
Q

Reflexes of Lower Limb and Myoclonus

A
  1. Knee jerk: Lift knee and relax to tap knee
  2. Ankle jerk: Bend knee to test ankle
  3. Plantar reflex: stroke for 3-5 seconds from sole to 1st MTPJ (L shape)
    - Babinski negative: S1 loops back to S1 - downgoing
    - Babinski positive: slow extension - spinal cord disorder disinhibition, S1 stimulus activates L4, L5
    - Withdrawal: fast extension
    Use the term: positive plantars or negative plantars. Forgo use of Babinski term
  4. Myoclonus - at least 3 or more beats
    - Perform if DTR 2+, otherwise minimal value
    - Sustained: 5+
    - Present but not sustained: 4+
37
Q

Power of Lower Limb

A
  1. Active lift whole LL up - can also see downdrift and ataxia if present
  2. Hip flexion/extension - push leg up or down against hand
  3. Hip abduction/adduction
    (do not force open or close the thighs - rude!)
    - Turn to lateral side
    - Press lateral surface of gluteus region for gluteus minimus
    - Press down over lateral thigh
  4. Hip internal/external rotation
    - Lift leg up, bend knee 90 degree, passive internal/external rotate then ask to push against resistance
  5. Knee flexion/extension - in neutral position
  6. Ankle dorsiflexion and eversion concurrently
    - Push against hand when dorsiflexed
    - Push Inversion for resistance
  7. Ankle plantarflexion and inversion concurrently
    - Push against hand when plantarflexed
    - Push eversion for resistance
  8. Toe flexion and extension
38
Q

Sensation for LL (6 points)
- UK examination is very particular about hygiene

A

Perfect reference point: forehead - but hygiene issue
Then test sternum - if equal, to use it as indirect reference point

Anterior thigh - L2 + femoral
Medial aspect of knee - L3 + femoral
Medial malleoli - L4 + saphenous branch of femoral nerve
distal lateral malleoli - L5 + superficial peroneal
1st dorsal webspace - L5 + deep peroneal
lateral side of foot - S1 + tibial nerve
(Try to avoid soles (S1) - cleanliness issue)

Peripheral neuropathy
Distal to proximal (x1 medial, x1 lateral) to obtain level of sensation (over dorsum of foot)
(Avoid soles/plantars - cleanliness issue)

39
Q

Heel shin dysmetria

A

3 point movement
- slide heel down to shin
- lift leg upwards (no need finger or palm as reference - most patients will likely miss)
- downward back to anterior knee

Observe for jerky or wavy heel from knee to shin

40
Q

Romberg test and walking patient

A

Sit patient to side, check no truncal ataxia first
Then stand patient
Both arms hugging
Eyes closed

Test for tabes dorsalis - sensory ataxia
- Dysequilibium on eyes closed

Do not perform in cerebellar ataxia - patient will definitely fall -> dangerous!

41
Q

Ulnar nerve

A

Flexor digitorum profundus
- Little finger IPJ

1st dorsal interrosei wasting

Dorsal sensory branch

Bilateral ulnar neuropathy - mononeuritis multiplex
Need to do blood panel: HbA1c, ESR, ANCA, HIV, Syphilis, PTB
Got 1 case suay - bilateral ulnar tunnel syndrome with surgical scars

Ix:
NCS - confirm, nature (axonal vs demyelinating vs focal)
MRI arm - compressive lesion
Refer HRM or ortho

42
Q

Radial Nerve

A

RN comes out together with axillary nerve
- Check deltoid bulk

3 proximal Sensory nerve over lateral arm, brachioradialis

Triceps weakness

Extensor carpi radialis longus (ECRL)

Deep and superficial nerve
superficial - Dorsum hand numbness, snuffbox area
Deep - pierce supinator muscle
> PIN syndrome: finger and wrist drop
- Test index finger

43
Q

Sequence of examination of cranial nerves

A

Exposure and Inspection

CN1 - ask for loss of smell
CN 2 - gross visual acuity and field, pupil constriction, light reflex
CN 3, 4, 6 - H test for EOM, saccades

The rest either in CN sequence (avoid missing out) or domains (demonstrates finesse)
Motor: CN 7, 5, 9, 10, 12 then 11
Sensory: CN 5, 7, 8, 9, 10

Speech:
Majulah Singapura - Singapore
British Constitution - UK
Perpustakaan - Malaysia

Screen for long tract deficit (brainstem deficit):
Pronator drift
Dysmetria

44
Q

Exposure and inspection for CN

A

Seated up, fully expose face, neck, INCLUDING shoulders and upper limbs

Face - facial dysmorphism, asymmetry, blepharoptosis, strabismus, abnormal posture (torticollis)

Look at trapezius wasting - spinal accessory nerve
Look at hands and fingers - wasting, Horners

Look behind the auricles and SPLIT the hairs
- Posterior cranial fossa scars
- Ear abnormalities - otorrhoea, vesicles

Look at surroundings for walking aids

45
Q

CN 1 - olfactory nerve

A

CN1: smell - olfactory nerve endings from upper part of nasal mucosa to CNS

Test: ask the patient - do you notice any change or loss in sense of smell or taste

Formal testing with coffee powder or test batteries usually not done

46
Q

CN2 - optic nerve

A

1. Visual acuity
- Test each eyes individually
- Can you see the numbers? use small numbers (1 to 3) (Do not use 5)
- Mini Snellen’s chart 3 metres away (usually not done in PACES anymore)

2. Colour
- Big red ball - (usually not done - quite pointless, only testing 1 colour)

3. Visual field
- Close 1 eye with hand, look at my eye (we may or may not need to close our own eye)
- Use big red ball
- From the side of quadrants all the way to the centre, ask:
1. Let me know when it appears
2. Inform me if disapepars

4. Pupillary light reflex and RAPD
(See subsequent cards)

47
Q

Pupillary light reflex

A

Tested in dark room with yellow light

Stand at patient’s side and ask him to look far (avoid accommodation reflex)

  1. Anisocoria
    - Shine from far away to look at both pupils - equal or unequal (anisocoria)
  2. Pupillary constriction
    - Shine from the side then move closer, observe constriction
48
Q

Consensual light reflex and relative afferent pupillary defect (RAPD)

A

Consensual light reflex
- Swing 1 second in oblique manner (NOT directly in front of patient’s eye)
- RAPD is tested with 1 torch - real PACES only 1 torch provided
-When swing to the next eye, eye will dilate first (from previous consensual constriction) then re-constrict back

If RAPD positive:
- Affected eye - no constriction
- Swinging eye to unaffected - no dilatation, only constriction
- Swing back to affected eye - from constrict to dilatation (from consensual reflex constriction), no re-constriction
- Offer to do fundoscopy on both sides

49
Q

CN3 - oculomotor nerve

A

CN3 - occulomotor nerve
- Medial rectus - adduction
- Superior rectus - upgaze
- Inferior rectus - downgaze
- Inferior oblique - upward abduction
- Levator palpebrae superioris - elevates superior eyelid
- Ciliary ganglion - pupillary constriction
- Ciliary muscle - lens accommodation

Origin:
- Oculomotor nucleus (midbrain) - EOM
- Erdinger-Westpal nucleus - constriction and accommodation
- No decussation

Deficit:
1. Ipsilateral downward outward deviation
- Unopposed CN4 and CN6 action
2. Ipsilateral ptosis
3. Ipsilateral mydriasis

50
Q

CN4 - trochlear nerve (SO4)

A

CN4 - trochlear nerve (SO4)
- Superior oblique - downgaze abduction

Origin and course:
- Trochlear nucleus (midbrain), decussate at midbrain-pons junction, exits from posterior
- Superior oblique is hooked around a trochlear

Deficit:
1. Ipsilateral upwards outwards deviation
2. Diplopia
3. Compensatory head tilt

51
Q

CN6 - abducens nerve (LR6)

A

CN6 - abducens nerve (LR6)
- Lateral rectus - abduction

Origin and course:
- Abducens nucleus (pons)
- No decussation for main pathway
- Exits at pons-medulla junction

  • Alternate pathway: medial longitudinal fasciculus
  • Decussate to control contralateral medial rectus muscle
  • Coordinates eye movements (eg: LE abduct, RE controlled to adduct)

Deficit:
1. Ipsilateral adduction deviation
- Unopposed medial rectus muscle
2. Diplopia

52
Q

Extraocular Muscles (CN3, CN4, CN6) testing

A

Slow pursuit - Double H
- Adequate distance
- Not too fast, or else pursuit will be broken
- Hold at extreme ends to look for nystagmus
- Change hand when going the other side
- Red pin held horizontally

53
Q

Saccades

A
  • Red ball held next to you
  • Alternative looking at red ball and your nose both horizontal and vertical

Vertical saccade - PSP
Horizontal saccade - INO

54
Q

CN5 - trigeminal nerve (mixed)
V1 - ophthalmic
V2 - maxillary
V3 - mandibular

A

Motor
V3 - masseters, temporalis muscle
- Bite down and clench jaw strongly
- Palpate temporalis and masseter muscle

Sensory
Test with cotton bud: pontine nucleus
Test with pinprick: spinal nucleus, medullary lesion

V1 - both sides of forehead
V2 - lateral to the nose (do not test over maxilla as there is overlap between V2 and V3)
V3 - both sides of jaw

55
Q

CN7 - facial nerve (mixed)

A
  1. Forehead asymmetry
    - Look up, wrinkle forehead
  2. Orbicularis oculi weakness
    - Squeeze eyes shut, bury eyelashes
    - Test power of 1 eye at a time with both index fingers
  3. Facial asymmetry
    - Observe for drooping
    - Puff cheeks
    - Smile, show your lower teeth - platysmal asmmyetry
56
Q

CN8 - vestibulocochlear nerve (sensory: hearing)

A

Tested with 512Hz tuning fork
Tuning fork with both prongs parallel (not perpendicular) to the ear

Normal
Rinne test: AC > BC
Weber test: equal

CDHL: Rinne BC > AC, Weber affected louder
SNHL: Rinne AC > BC, Weber normal louder

57
Q

CN9 - glossopharyngeal nerve (mixed)
CN10 - vagus nerve (mixed)

A
  1. Palatal and uvula deviation
    - Open mouth, say “ahhhh”
58
Q

CN11 - accessory nerve (motor)

A
  1. Sternocleidomastoid muscle
    - Turn your head to one side then the other, palpate SCM muscles
  2. Shoulder shrug - trapezius
    - Shrug shoulders, push down against them
59
Q

CN12 - hypoglossal nerve (motor)

A
  1. Tongue deviation
    - Stick out your tongue
  2. Tongue weakness
    - Push tongue against cheeks
60
Q

Screening for long tract deficit (brainstem deficit)

A
  1. Pronator drift
  2. Dysmetria
  3. Hypertonia
  4. Hyperreflexia

MRCP PACES Neurology (28 decks)

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